Family functionality in oldest old household residents

Objective: the aim of this study was to identify factors associated with family functionality of non-institutionalized long-lived subjects, who were residents in Goiânia (GO), Brazil. Method: this was a population-based epidemiological study with cross-sectional outline. Evaluation scales of the functional and cognitive capacities were used. Family dynamics was measured using the Adaptation, Partnership, Growth, Affection, and Resolve (APGAR) instrument by making home interviews with 131 long-lived individuals. Results: there was prevalence of the female gender, average of age of 83.87 years old, widowhood condition, and residence in a big family, primary schooling, and self-perception of regular health. A great amount showed independence for self-care and partial dependence for daily life instrumental activities. Family functionality prevailed with score average of 9.06 points. Conclusion: in conclusion, family functionality in long-lived subjects is associated with self-perception of poor/bad health, osteoporosis, and fall. Results allowed characterizing long-lived subjects’ family functionality with the aim of valuing and prioritizing family as a caregiver.


INTRODUCTION
The worldwide phenomenon of aging reveals that oldest old, identified as people aged greater than or equal to 80 years old are advancing rapidly in numbers, especially in developing countries (1) .The 14 million oldest old identified in the 20 th century will correspond to, in 2050, more than 400 million worldwide.The highest prevalence is related to gender, for each group of 100 oldest old women, there are 61 men of the same age group (1) .
In Goiânia (GO), the oldest old have already reached 7.9% of the elderly population (2) .The heterogeneity of the elderly population is directly influenced by the decline in mortality in advanced ages, gender, marital status, geographic region and people's accessibility to social and economic conditions.The longevity of humanity should be seen as a triumph of development and one of the greatest achievements of humanity (3)(4) .
Endless opportunities about this triumph of development are related to the adoption of new policies, strategies and laws on the development due to the different characteristics, such as age, gender, ethnicity, education, income and health (1) .Among the strategies, health promotion and healthy behaviours at all ages are needed to reduce, prevent and delay the onset of chronic diseases, through less exposure to risk behaviours throughout life (4) .
The challenges are related to the recognition that the aging of populations is a worldwide reality, and therefore, transformations are necessary in a society where these people are inserted, such as income guarantees, access to quality healthcare services and environments that stimulate and facilitate the coexistence of people with functional disabilities, that is, their home (1) , above all, meeting this stratum of the population is essential in relation to demographic conditions and health, functional capacity and Family Functionality (FF).
This silent evolution in intergenerational family demographics has provided the conviviality of the elderly with a greater number of generations and a lesser amount of relatives by generation.Such conviviality is an opportunity for structural transformations inside the family context, with contributions and assignments linked to different actors.
The forms of family grouping have been modifying since 1960, being sculpted by social features (individualism and immediate consumption of material objects, among others), changing intra-family relations (5)(6) .
The investigation of family dynamics explores and visualizes if there is harmony or disharmony in family relationships, from the perspective of the elderly in old age, in relation to care received from his/her family, as a stressor or protective factor (7) .Subjective aspects, such as adaptation to the new realities facing stressful situations, or sharing decisions and responsibilities in order to maintain its members protected and fed, supporting new ideas and directions, interacting emotionally in the family context and having shared time, can be evaluated before the family intervention.
A screening test is the Adaptation, Partnership, Growth, Affection and Resolve (APGAR) of family, through five questions, the test analyses the following domains: adaptation, partnership, growth, affection and resolve (7)(8) .High scores, resulting from the sum of the domains, reveal the family's ability to adapt to new situations and manage conflicts, with a view to FF, while low scores indicate an environment with low capacity to adapt to the new situation, requiring early intervention (9) .
Thereby, in the context of health care of people with 80 years or more, the APGAR instrument can be a strong ally in family relations evaluation and detection of risk factors that deserve intervention.Given the above, the objective of this study was to identify the factors associated with FF of the noninstitutionalized oldest old residents in Goiânia (GO), Brazil.

METHODS
Population-based epidemiological study with cross-sectional design through household interviews with elders, held in a Midwestern Brazilian capital, which had more than one million inhabitants.Of these, 7.9% were oldest old.
The study population consists of elderly living in urban areas from probabilistic sample array, from the database of the Network for Health Surveillance of the Elderly (REVISI).The sample calculation considered the following parameters: expected frequency of 30% for all the objectives of the research, a significance level of 5%, absolute precision of 5.0%, and design effect of 1.8.The representative sample was composed by 934 elderly.
The process of sampling was probabilistic by conglomerates, in multiple stages.In the first stage 56 census sectors were drafted, among 912 sectors of the urban municipality.For the second stage blocks, corners and domiciles to be visited were also drafted.
The sample met the following eligibility criteria: (1) age of 80 years or more; (2) residence in the Goiania urban area; (3) resident of the visited domicile; and (4) have answered all five questions about Family APGAR.Elderly who were drafted but did not reside in the family home were excluded, in addition to the questionnaires answered by caregivers and/or family members, the total number of excluded individuals was 131.
After the pilot test, we began data collection by trained interviewers, in the period of December 2009 to April 2010.Authorization was requested of the elderly by means of consent form (CF) and, in a private space, the semi-structured questionnaire was applied, it contained socioeconomic and demographic features, information about the caregiver, health condition and self-perceived pain, falls, hospitalization in the past year and access to health services.The assessment of functional capacity was measured by scales of basic activities of daily living (BADL), Instrumental Activities of daily living (IADL) and cognitive assessment via the Mini Mental State Examination (MMSE).The family dynamics, from the perspective of the elderly, was measured by Family APGAR index.
The BADL scale measures the independence in the performance of activities related to self-care (10) .This exposure variable was ordered in total independence, partial dependence and total dependence.The activities that assess the elderly in the environment and surroundings, through the IADL were scaled from 9 to 27 points, in which 9 refers to the total dependence and 27 refers to independence in the performance of these activities (11) .
The MMSE was applied to verify the cognitive function, having been chosen to be used in populational studies in the various practical scenarios (12) .As cut-off points, we used the years of education: 20 points for illiterate; 25 points to 1-4 years of study; 26 points for 5-8 years; 28 points to 9-11 years; and 29 points for more than 11 years.This test does not replace the neuropsychological assessment in subjects with low scores, requiring a verticalized investigation of functional loss (12)(13) .
In order to evaluate the family dynamics, we applied the APGAR Family (8) .The acronym APGAR derives from words Adaptation, Partnership, Growth, Affection and Resolve.The five domains are assigned values of zero, 1 and 2 points.Zero for the option "hardly ever", 1 for "some of the time" and 2 "almost always".The total sum of the scores oscillates on a scale from zero to ten points, in which: from zero to 4, indicates severely dysfunctional family (SDF); from 5 to 6, moderately dysfunctional family (MDF); and from 7 to 10, Functional Family (FF) (8,13) .In other words, the FF is expressed by ≥ 7 scores and Family Dysfunction (DF) by <7 points scores (8,13) .
In this sense, the exposure variables were socioeconomic and demographic characteristics, self-reported health conditions, functional and cognitive capacity.The FF was the outcome variable.
Data were entered in the Excel software for Windows ® 2003-2007 after double check.Data analysis was conducted by measures of absolute and relative frequency, mean and standard deviation in the IBM software Statistical Package for the Social Sciences (SPSS) for Windows ® version 20.0.For univariate association analysis between the FF of oldest old and exposure variables, Chi-square or Fischer tests were used, with significance level of 5%.The measurement of effect used was the prevalence ratio (PR).Multiple logistic regression was applied to identify the factors associated with the FF through the construction of the model with the predictor variables, which obtained p-value ≤ 0.20 in univariate analysis.
The variables entered into the multivariate analysis were scaled in two blocks, Block 1 socioeconomic demographic − (marital status, children, educational level, residents at household and type of residence); and Block 2 -self-perceived health conditions (self-perception of health, falls and demand for health services).
The ethical care that conduct research involving humans have been secured, according to Resolution 196/96 of the National Health Council, and the research was approved by the Research Ethics Committee of Universidade Federal de Goiás (UFG) under the protocol 050/2009.
Regarding Family APGAR domains, the first domain, "I am satisfied, because I can count on my family in case I need help when there is a disturbance or preoccupation" referred to the adaptation component.In this matter, 5 (3.8%) oldest old reported never being satisfied with the family member about the care received, 12 (9.2%)responded sometimes and 114 (87.2%) were always pleased to able to rely on family for help when needed.
The second domain referred to the Partnership component, "I am satisfied with the way my family and I talk and share problem".In this domain, 6 (4.6%) oldest old reported never being satisfied with the ability of the family to share decisions and responsibilities, 9 (6.9%) responded sometimes and 116 (88.5%) responded they were always satisfied with communication between his/her family members, as well as protection and food intended for them.This was the domain with the highest percentage of acceptability of the oldest old.
The third area, "I am satisfied with the way my family accepts and supports my desires to begin or to search for new activities and to search for new paths and directions", referred to the Growth domain.In this item, 6 (4.6%) oldest old reported never being satisfied with the way the family unit was managed, both in the structural and emotional areas, 16 (12.2%)responded sometimes and 109 (83.2 %) were always satisfied with the way which his/her family helped him/her.
The fourth domain, "I am satisfied with the way my family demonstrates affection and reacts to my emotions, such as anger, regret or love" referred to the Affection domain.In this item, 3 (2.3%)oldest old reported never being satisfied with the way the family unit was managed, both in the structural and emotional areas, 15 (11.5%) answered sometimes and 113 (86.3 %) were always satisfied with the care for the emotional interactions in the family context.
The fifth area, "I am satisfied with the way my family and I spend time together", referred to the Resolve domain in the family unit.In this latter domain, 5 (3.8%) oldest old reported never being satisfied with the response capacity of their family, 21 (16.0%)answered sometimes and 105 (80.2%) were always satisfied with the time they shared.
In the univariate analysis, we  4).

DISCUSSION
Most oldest old reported family dynamic with FF, demonstrating that the family was able to care for their elderly, as found in other studies (9,(14)(15) .
Among the domains of Family APGAR, FF was estimated in the Partnership domain, followed by adaptation, indicating that there is a greater family care for the elderly in relation to sharing decisions, responsibilities, protection and affection facing family stress situations, regarding family balance.Regarding time shared and problem solving, this domain was reported by the elderly as less attention by family members, confirming other findings (16) .On the other hand, this result suggests a vertical analysis of relationships and intergenerational living, as this greater contact with the elderly and greater family care demands can lead to DF by the impact of chronic diseases, in addition to triggering conflicts and dissatisfaction on the part of the elderly, who can promote changes of intra-family roles and main caregiver selection (17) .In this context, we highlight the ischemic heart disease, stroke (CVA), visual impairment and chronic obstructive pulmonary diseases (COPD) (4) .
Regarding self-reported health conditions, the elderly who reported worse health conditions showed a better family dynamics.It is known that the family is decisive for a successful aging process and the elderly quality of life (QOL) (18)(19) .In this context of aging and self-reported health conditions, there is a higher consumption of health services to the elderly, which is related to the individual's life path, resulting in lifestyle (4) , showing that the association between health and behaviour throughout life influences the QOL of elderly and the FF (20) .
In other words, aging and FF influence the QOL of people, that is, the higher the FF, the better QOL, and the older they get, the worse is their QOL (21) .The role of intra-family support in the elderly QOL proved to be a motivation factor for QOL and better health (22) .In this sense, the oldest old generation, because they are not homogeneous, requires vertically integrated policies to the real needs, considering gender, ethnicity, education, income and health (1) .
No studies that associate FF by Family APGAR and osteoporosis were found.However, the association between FF and osteoporosis may reflect family dynamics, as appropriate environments for physical activity, social support and infrastructure contribute to a more active behaviour and therefore greater functional independence and improved QOL (23) .
Regarding FF and the exposure variable falls, it is known that it can worsen the health status, on a downward spiral, resulting in long-term care due to the increased possibility of dependence, loss of autonomy, confusion, immobilization, depression and death (4) .These factors can influence the FF and changing family dynamics, due to increased demand for attention, the changing roles and new styles of family relationships (9) .

CONCLUSION
After multivariate analysis, the Family Functionality, in the oldest old, remained associated with self-perceived poor/very poor health, osteoporosis and falls.These results fill a gap in the literature, since this ground breaking research in the Brazilian Midwest also allows better characterization of the oldest old on Family Functionality.
Given the demographic and epidemiological transition experienced in contemporary times, the elaboration and the applicability of existing public policies to the real needs of low income women are necessary.Therefore, the results contribute to clinical practices for better planning and family strengthening in home care with support and care of Nursing professionals engaged in primary care, that is, in home care, family should be prioritized as a caregiver and partner in the care of these people.
However, methodological limitations of this study should be considered, especially the cross-sectional design, which did not allow causal relationship inferences between Family Functionality and associated factors.

Table 2 -
Family Functionality and self-perception of disease.hospitalization and oldest old falls in the city of Goiânia (GO).

Table 3 -
Family functionality according to the presence of caregiver, functional capacity and Mini Mental State Examination (MMSE) in the oldest old in the city of Goiânia (GO), 2010 (n=131) *p-value<0,05.PR: prevalence ratio; 95%IC: 95% confidence interval; DLBA: Daily Life Basic Activities; IADL: Instrumental Activities of Daily Living.